PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge IN THE MATTER OF ___________________________________________________________ CASE NUMBER ___________________________________________________ APPLICATION FOR APPOINTMENT OF CONSERVATOR [R.C. 2111.021] I, ___________________________________ , Petitioner, hereby state that I am a competent adult but am physically infirm. I request that : 1. Name of Proposed Conservator _____________________________________________________________ Street _________________________________________________________________________________ City ________________________________ , Ohio (Zip) ___________ Telephone ( _____ ) ___________ be appointed conservator of my: 9 Person and Estate 2. 9 Estate Only The length (time period) of the conservatorship is: 9 Indefinite 3. 9 Person only 9 Definite - to ______________________________, 20_____ (If “Person Only” or Person and Estate” is checked), I give the following power over my PERSON to the: a. Conservator: 9 (1) 9 (2) All powers that a guardian would have under the guardianship laws of Ohio. Limited to the power to _______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ b. Court: 9 (1) 9 (2) All powers that a Court would have under the guardianship laws of Ohio. Limited to the power to _______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 4. (If “Estate Only” or “Person and Estate” is checked), I give the following power over my ESTATE to the: a. Conservator: 9 (1) 9 (2) All powers that a guardian would have under the guardianship laws of Ohio. Limited to the power to _______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Form 20.0 - Application for Appointment of Conservator 03/00 American LegalNet, Inc. www.FormsWorkflow.com b. Court: 9 (1) 9 (2) All powers that a Court would have under the guardianship laws of Ohio. Limited to the power to _______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ c. The following of my property is subject to: 9 (1) 9 (2) All property. (Attach description of property) Only the property listed as follows: _____________________________________________ __________________________________________________________________________ __________________________________________________________________________ 5. If the application is for a conservatorship of the estate: a. The estate to be placed under conservatorship is: Personal Property $ _________________________ Real Property $ _________________________ Annual Rents $ _________________________ Other Annual Income $ _________________________ TOTAL $ _________________________ B. A bond in the amount of $ __________________________ is attached. (R.C. 2109.04(A)(1)(Form 15.3) 6. Service of notice to the conservatorship is to be given to: 9 None 9 Same as Guardianship 9 As Listed on Form 15.0 Based on the foregoing information, I do hereby petition the Court to appoint a Conservator for myself, and do so freely and of my own will. I certify that all information and statements contained in this application and the attached exhibits are correct to the best of my knowledge and belief. ________________________________________ Date _______________________________________ _______________________________________ Attorney’s Signature Applicant’s Signature _______________________________________ _______________________________________ (Type or Print Attorney’s Name) Type or Print Applicant’s Name _______________________________________ (Street) _______________________________________ ___________________________________________ ___________________________________________ Address (City, State, Zip Code) Address (City, State, Zip Code) (Street) ___________________________________________ ___________________________________________ Telephone Number include area code Telephone Number include area code ___________________________________________ Supreme Court Registration Number. American LegalNet, Inc. www.FormsWorkflow.com